Healthcare Provider Details

I. General information

NPI: 1912747437
Provider Name (Legal Business Name): SMB MEDICAL GROUP DE, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2024
Last Update Date: 05/31/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1S376 SUMMIT AVE BLDG C
OAKBROOK TERRACE IL
60181-3985
US

IV. Provider business mailing address

1S376 SUMMIT AVE BLDG C
OAKBROOK TERRACE IL
60181-3985
US

V. Phone/Fax

Practice location:
  • Phone: 415-835-4794
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: SANDEEP KHOSLA
Title or Position: PRESIDENT
Credential: MD
Phone: 415-835-4794